Efficacy of cartilage palisade tympanoplasty: randomized controlled trial

To Study the Outcome of Cartilage Tympanoplasty Type I in Patients with Medium and Large Perforations Using 0.5 mm Sliced Conchal Cartilage Reinforced with Temporalis Fascia Grafts with 5 Years Follow-up

Aims

To study the outcome of cartilage tympanoplasty type I in patients with medium and large perforations using 0.5 mm sliced conchal cartilage reinforced with temporalis fascia grafts with 5 years follow-up.

Study Design

Retrospective clinical study.

Patients and Method

120 patients with dry tympanic membrane perforation medium and large size and intact ossicular chain, and with no history of previous ear surgery were selected. An underlay type one tympanoplasty, using 0.5 mm sliced conchal cartilage reinforced with temporalis fascia, was performed during 2018-19. A successful anatomical outcome was considered to comprise full, intact healing of the graft without perforation these patients were evaluated for at least 5 years post-operatively till 2023.

Results

In this study graft uptake rate was 95.33% for medium size and 93.66% for large perforations at 3 months and after 5 years of follow-up 92.77% medium size and large size perforations were 89.67.66% (P < 0.001). Residual perforations were there in about 7.29% in medium and 10.33% in large size perfrations.

Conclusion

Sliced conchal cartilage reinforced with temporalis fascia is a reliable technique for tympanoplasty, with improved graft uptake results in medium and large perforations in the long-term, also the residual perforations is significantly lower.

The role of allergic and nonallergic rhinitis on success of type 1 cartilage tympanoplasty

OBJECTIVE

To investigate the role of allergic rhinitis (AR) and non-allergic rhinitis (NAR) on success of type 1 cartilage tympanoplasty.

METHODS

This prospective study was conducted on 60 patients who had type 1 cartilage tympanoplasty. The patients were divided into three groups as no-rhinitis (n = 28), NAR (n = 18) and AR (n = 14) groups, based on their symptoms, skin prick tests and/or serum specific IgE levels. AR and NAR groups were treated for their rhinitis symptoms both pre- and postoperatively. The patients were followed up for a minimum of 6 months and compared for graft success rates and audiological outcomes.

RESULTS

Three study groups were similar for age, gender distributions and preoperative air-bone gaps (p = 0.780, p = 0.167 and p = 0.676, respectively). Postoperative graft perforation rate was 0% in no-rhinitis and AR groups while it was 16.7% in NAR group, with a significant difference among three groups (p = 0.034). The comparison of three study groups for change in the postoperative air bone gaps in comparison with preoperative air bone gaps did not yield any statistically significant result (p = 0.729).

CONCLUSION

Although AR does not result in failure of type 1 cartilage tympanoplasty in patients treated for rhinitis compared to the control group, NAR does. Pre- and postoperative treatment of patients for rhinitis and employment of cartilage graft may be the key factors for success of surgery in patients with AR. Further studies with a larger sample size are needed.

Efficacy of autologous platelet-rich plasma on graft uptake in myringoplasty: a single-blinded randomized control trial

Background and aim

Chronic otitis media is defined as a chronic inflammation of the middle ear cleft producing irreversible pathological changes. The myringoplasty aims at the reconstruction of the tympanic membrane using a graft material. Autologous platelet-rich plasma can be used along with the graft to have a successful outcome. The aim of the study was to assess the efficacy of autologous platelet-rich plasma on graft uptake in myringoplasty.

Methods

This was a randomized controlled trial with a sample size of 76 patients. All patients were above 18 and below 55 years of age diagnosed with chronic suppurative otitis media and were planned for myringoplasty. The participants were randomly allotted to two groups by block randomization (block of 4). Intra-operatively, group I (n=38) received platelet-rich plasma–soaked gel foam and group II (n=38) was taken as the control group who received saline-soaked gel foam and examined by a blinded examiner at the end of 1st and 3rd months.

Results

The mean air-bone gap reduction post-operatively in the platelet-rich plasma group was 8.68 ± 4.8 (P value 0.034) and 6.05 ± 4.05 in the control group. The improvement in pure-tone average in the platelet-rich plasma group (P = 0.009) is more than that in the control group. The graft uptake was higher among the platelet-rich plasma group than the control group both at 1st and 3rd months (P value 0.049) which were statistically significant.

Conclusion

The present study concludes that the usage of platelet-rich plasma in the conventional myringoplasty technique has improved the success rate of graft uptake and reduced the graft migration.

Trial registration

Clinical Trials Registry-India (ICMR-NIMS) CTRI/2020/04/024416. Date of registration: 01/04/2020. Date of enrolment of the first participant to the trial: 06/04/2020. URL of the trial registry: http://www.ctri.nic.in.

Highlights

Usage of autologous platelet-rich plasma (PRP) in conventional myringoplasty in underlay technique.

Assessment of graft uptake, percentage of perforation closure, and the audiological outcome.

Significant mean reduction of ABG in the PRP group.

Significant improvement in PTA average in the PRP group.

Graft uptake and percentage of perforation closure were higher in the PRP group and the control group.

PRP is also beneficial in revision cases.

Type 1 Tympanoplasty Outcomes between Cartilage and Temporal Fascia Grafts: A Long-Term Retrospective Study

Background: To compare the functional and anatomical results of two different types of grafts in type 1 tympanoplasty (TPL I). Methods: A retrospective comparative bicentric study was conducted on patients treated with TPL I using temporal fascia or tragal cartilage. We evaluated the functional and anatomical results with intergroup and intragroup analyses. Variables predicting long-term success were also evaluated. Results: A total of 142 patients (98 fascia graft vs. 44 cartilage) were initially assessed, with a mean follow-up of 67.1 ± 3.2 months. No significant differences were observed between the two groups on the intergroup analysis of age, gender, ear side, or pre-operative hearing data (all p > 0.05). At the intragroup analysis of auditory outcomes, both groups demonstrated a significant improvement in post-operative air conduction, with greater gain for the fascia group at 6 months follow-up (p < 0.001 for both); however, at long-term follow-up, cartilage demonstrated better stability results (p < 0.001). When comparing the pre-and post-operative air-bone-gap (ABG), both groups showed a significant gain (p < 0.001); the fascia group showed that at 6 months, a greater ABG increase was found, but the difference was not statistically significant (4.9 ± 0.9 dB vs. 5.3 ± 1.2 dB; p = 0.04). On the contrary, the cartilage group at long-term follow-up at 5 years maintained greater outcomes (10 ± 1.6 dB vs. 6.4 ± 2 dB; p < 0.001). Lower age (F = 4.591; p = 0.036) and higher size of perforation (F = 4.820; p = 0.030) were predictors of long-term functional success. Conclusions: The graft material selection should consider several factors influencing the surgical outcome. At long-term follow-up, the use of a cartilage graft could result in more stable audiological outcomes, especially in younger patients or in case of wider perforations.

Cartilage Tympanoplasty: A Review on Its Postoperative Outcomes on Hearing

Cartilage graft tympanoplasty has a better success rate in the treatment of chronic otitis media if properly prepared pre-operatively and placed intraoperative. To prepare cartilage graft from tragus and to compare pre-operative and postoperative hearing. 35 patients with chronic otitis media of tubotympanic type, without intra/extra cranial complications disease were made to undergo cartilage tympanoplasty. The study was conducted prospectively. In this technique, patients had an average improvement in hearing up to 10-12 dB. The mean post-operative period follow up was 2-6 months. If cartilage graft is properly prepared and placed, cartilage tympanoplasty appears to provide better success rates and hearing results.

Predictors of anatomical and functional outcomes following tympanoplasty: A retrospective study of 413 procedures

OBJECTIVES

To identify the predictors of anatomical and functional outcomes following tympanoplasty.

STUDY DESIGN

A retrospective cohort study.

METHODS

Patients with chronic suppurative otitis media (CSOM) who underwent a tympanoplasty at Peking Union Medical College Hospital from January 1, 2015 to December 31, 2019 were retrospectively included. Outcome measures included graft success and postoperative pure tone audiometry air-bone gap (PTA-ABG) at last follow-up (≥6 months). PTA-ABG and MERI were calculated. Descriptive, univariable, and multivariable logistic regression analyses were conducted to evaluate the predictors of the graft and hearing outcomes.

RESULTS

During the study, 385 patients (167 male, 218 female, median age 44 years) undergoing 413 procedures were studied. Out of this, 219 ears underwent tympanoplasty, 45 ears had tympanoplasty with canal wall up mastoidectomy, and 149 ears had tympanoplasty with canal wall down mastoidectomy. At the last follow-up, the overall graft success rate was 91.3% (377/413) and the overall hearing success rate was 40% (165/413). Multivariable analysis results showed that the obstructed aditus ad antrum (OR 2.67, 95%CI 1.13-6.30; P = .025) was an independent prognostic factor for graft failures. Moreover, the obstructed aditus ad antrum (OR 2.18, 95%CI 1.16-4.08; P = .015) and MERI >3 (OR 6.53, 95%CI 3.55-12.02; P < .001) were independent predictors of hearing failures (PTA-ABG > 20 dB).

CONCLUSIONS

Aditus ad antrum patency was an independent predictor of both graft and hearing success among patients following tympanoplasty. MERI score greater than three was found to be a significant predictor of postoperative hearing and could serve as a useful tool for assisting clinicians in perioperative risk assessment.

LEVEL OF EVIDENCE

4.

Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review

OBJECTIVE

To assess the effectiveness of tympanoplasty in treating chronic otitis media-related hearing loss, published literature was systematically reviewed to determine the clinical success rate of tympanoplasty at restoring hearing in chronic otitis media patients at a minimum follow-up period of 12-months.

DATA SOURCES

PubMed, Embase and the Cochrane Library.

METHODS

Two independent reviewers performed literature searches. Publications reporting long-term (≥12-month) hearing outcomes and complications data on adult and pediatric patients with chronic otitis media were included and assessed for risk of bias and strength of evidence. To assess how tympanoplasty influences long-term hearing outcomes, data on pure tone audiometry (air-bone gap) and complications were extracted and synthesized.

RESULTS

Thirty-nine studies met the inclusion criteria. Data from 3162 patients indicated that 14.0% of patients encountered postoperative complications. In adult patients, mean weighted air-bone gap data show closure from 26.5 dB hearing level (HL) (preoperatively) to 16.1 dB HL (postoperatively). In studies that presented combined adult and pediatric data, the mean preoperative air-bone gap of 26.7 dB HL was closed to 15.4 dB HL. In 1370 patients with synthesizable data, 70.7% of patients had a postoperative air-bone gap ˂ 20 dB HL at long-term follow-up. Finally, subgroup analysis identified that mean improvement in ABG closure for patients with and without cholesteatoma was 10.0 dB HL and 12.4 dB HL, respectively.

CONCLUSION

In patients with chronic otitis media, tympanoplasty successfully closed the air-bone gap to within 20 dB HL in 7/10 cases and had an overall complication rate of 14.0%.

LEVEL OF EVIDENCE

2a.

Success rate of type 1 tympanoplasty: a comparative study

OBJECTIVES

This study aimed to compare graft take rate after tympanoplasty between adults and paediatric patients, cartilage and fascia grafts, and overlay and underlay techniques.

METHODS

Data were analysed in groups according to the technique (underlay vs overlay), age (paediatric patients vs adults) and graft (cartilage vs temporalis fascia). The main outcome measures were full graft take and the incidence of complications.

RESULTS

A total of 198 patients (208 ears) were included. Overall, full graft take was achieved in 200 ears (96 per cent). The success rate was higher in adults compared with paediatric patients (97.5 per cent vs 92.25, respectively) but the difference was insignificant. Similarly, higher but insignificant graft take rate was found in the cartilage group compared with fascia group (98.6 per cent vs 94.9 per cent, respectively).

CONCLUSION

All cases of overlay tympanoplasty had full graft take (success rate 100 per cent). In the underlay group, successful graft take was achieved in 154 cases (95 per cent). This difference was statistically insignificant.

Long-term results of type I tympanoplasty with perichondrium reinforced cartilage palisade vs temporalis fascia for large perforations: A retrospective study

Objective

To compare the rate of graft uptake and postoperative hearing outcomes of Type I tympanoplasty with perichondrium reinforced cartilage palisade to temporalis fascia for large tympanic membrane (TM) perforations over 5 years follow-up period.

Materials and methods

This was a retrospective comparative study involving patients with chronic otitis media with large TM perforations. The patients underwent type I tympanoplasty using either perichondrium reinforced cartilage palisade (CP group) or temporalis fascia (TF group) as the graft via a transmeatal approach and under local anesthesia. Morphological and functional results were recorded at three- and five years follow-up. Demographic profiles including age and sex, surgery side, contralateral disease and graft uptake rate, as well as hearing outcomes, were compared between the two groups.

Results

At three years follow-up, graft uptake was 94.87% for perichondrium reinforced cartilage palisade and 80.7% for fascia, respectively, (p = 0.67). At five years follow-up, the uptake rate dropped to 87.17% in the CP group, but to 66.6% in the TF group (p=0.019). Hearing improved after surgery in both groups, and showed no significant difference between the two groups.

Conclusion

Over long-term, perichondrium reinforced palisade showed a statistically significant better outcome regarding graft uptake than temporalis fascia in type Itympanoplasty for large TM perforations with comparable audiometric results

Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study

PURPOSE

The endoscopic approach to tympanoplasty is gaining popularity, but its adoption for the palisade tympanoplasty technique is unstudied. The aim of the present study was to evaluate the effectiveness of endoscopic cartilage palisade tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for tympanic membrane closure in adult patients with subtotal perforations.

METHODS

Retrospective study of 42 adult patients who underwent endoscopic tympanoplasty for a subtotal perforation in a university tertiary referral center from January 2018 to June 2019. Patients underwent transcanal tympanoplasty either with cartilage palisade grafts or with one-piece composite cartilage-perichondrium grafts. Both techniques were compared for graft take rate and audiometric results.

RESULTS

Twenty palisade and 22 single-piece tympanoplasties were analyzed. No statistically significant differences between groups were found in terms of tympanic membrane closure (85% vs. 86.3%, p = 0.5) or hearing improvement.

CONCLUSION

The results of the present study suggest that similar results can be obtained with palisade cartilage grafts compared to the one-piece composite cartilage-perichondrium technique for endoscopic tympanic membrane closure. Further studies with long-term results will be needed to confirm these findings.

Success rates for various graft materials in tympanoplasty - A review

Objectives

The aim of this paper is to review how successful each type of grafts is in tympanoplasty.

Methods

Pubmed, Google and the Proquest Central Database at Kırıkkale University were queried using the keywords “graft”, “success” “tympanoplasty”, “success rate” with the search limited to the period 1955 to 2017.

Results

Various types of graft materials including temporalis fascia, cartilage, perichondrium, periosteum, vein, fat or skin have been used in the reconstruction of tympanic membrane (TM) perforation. Although temporalis fascia ensures good hearing is restored, there are significant concerns that its dimensional stability characteristics may lead to residual perforation, especially where large TM perforations are involved. The “palisade cartilage” and “cartilage island” techniques have been stated to increase the strength and stability of a tympanic graft, but they may result in a less functional outcome in terms of restoring hearing. Smoking habits, the size and site of a perforation, the expertise level of the operating surgeon, age, gender, the status of the middle ear mucosa and the presence of myringosclerosis or tympanosclerosis are all important in determining how successful a graft is.

Conclusion

Although temporal fascia is the most commonly used graft material for tympanoplasty, poor graft stability may cause failure. This failure is due to the inclusion of connective fibrous tissue containing irregular elastic fibers present in the grafted fascia. Cartilage grafts offer better ability to resist infection, pressure, and cope with insufficient vascular supply. This means that cartilage grafts are suitable for use in revision cases.

To Compare Short and Long-Term Graft Uptake and Hearing Outcome of Type I Cartilage Tympanoplasty Between Small, Medium and Large Perforations Using Reinforced Sliced Conchal Cartilage

To compare short and long-term graft uptake and hearing outcome of type I cartilage tympanoplasty between small, medium and large perforations using reinforced sliced conchal cartilage. A retrospective study conducted in a tertiary center. Fifty patients who under went type I tympanoplasty were enrolled. Their mean age was 29.30 years and follow-up time was 6 and 18 months. The preoperative, postoperative short-term and long-term hearing and graft uptake results were analyzed. Graft uptake rate was 96% in short-term and 98% in long-term with one residual perforation in medium size, but 100% in small and large perforations (P < 0.01). Short and long-term ABG closure was identical in small and medium size perforation (P = 0.978) (P = 0.734), but, large perforation showed significant improvement in long-term (P = 0.012). Sliced conchal cartilage reinforced with temporalis fascia is a reliable technique for tympanoplasty. In long-term, large perforations have better graft uptake rate and continuous hearing improvement and ABG closure than small and medium perforations.

Impact of platelet-rich fibrin therapy in tympanoplasty type 1 surgery on graft survival and frequency-specific hearing outcomes: a retrospective analysis in patients with tympanic membrane perforation due to chronic otitis media

OBJECTIVE

To evaluate the impact of platelet-rich fibrin therapy in tympanoplasty type 1 surgery on graft survival and frequency-specific hearing outcomes.

METHODS

Patients who underwent tympanoplasty type 1 surgery were randomised into temporal fascia graft alone (n = 55) and temporal fascia graft plus platelet-rich fibrin therapy (n = 36) groups. Graft survival and hearing outcomes were recorded.

RESULTS

Graft survival rates were significantly higher in the temporal fascia graft plus platelet-rich fibrin therapy group than in the temporal fascia graft alone group at one (100.0 vs 85.5 per cent, p = 0.020), three (97.2 vs 80.0 per cent, p = 0.024) and six months post-operatively (94.4 vs 74.5 per cent, p = 0.031). The difference in hearing gain between groups was not significant.

CONCLUSION

Our findings revealed that the use of a platelet-rich fibrin plus temporal fascia graft for type 1 tympanoplasty was associated with more favourable post-operative outcomes than the use of temporal fascia alone, both in terms of tympanic membrane healing and graft survival; hearing restoration outcomes were similar.

A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty

Introduction  The use of endoscope is rapidly increasing in otological and neuro-otological surgery in the last 2 decades. Middle ear surgeries, including tympanoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Superior visualization and transcanal access to diseases normally managed with a transmastoid approach are touted as advantages with the endoscope.

Objectives  The present study aimed to compare the outcomes of endoscopic and microscopic cartilage tympanoplasty (Type I)

Methods  This was a retrospective comparative study of 70 patients (25 males and 45 females) who underwent type I tympanoplasty between March 2015 and April 2016. The subjects were classified into 2 groups: endoscopic tympanoplasty (ET, n  = 35), and microscopic tympanoplasty (MT, n  = 35). Tragal cartilage was used as a graft and technique used was cartilage shield tympanoplasty in both groups. Demographic data, perforation size of the tympanic membrane at the preoperative state, operation time, hearing outcome, and graft success rate were evaluated.

Results  The epidemiological profiles, the preoperative hearing status, and the perforation size were similar in both groups. The mean operation time of the MT group (52.63 ± 8.68 minutes) was longer than that of the ET group (48.20 ± 10.37 minutes), but the difference was not statistically significant. The graft success rates 12 weeks postoperatively were 91.42% both in the ET and MT groups, that is, 32/35; and these values were not statistically significantly different. There was a statistically significant improvement in hearing within the groups, both pre- and postoperatively, but there was no difference between the groups.

Conclusion  Endoscopic tympanoplasty is a minimally invasive surgery with similar graft success rate, comparable hearing outcomes and shorter operative time period as compared to microscopic use.

Rates of success in hearing and grafting in the perichondrium-preserved palisade island graft technique

INTRODUCTION

Various graft materials have been used in the tympanoplasty technique. Cartilage grafts are being used increasingly in recent years.

OBJECTIVE

The aim of this study was to present the comparative outcomes of the perichondrium-preserved palisade island graft technique previously defined by ourselves.

METHODS

We retrospectively compared the hearing and graft success rates in 108 patients with chronic otitis media, who had undergone cartilage tympanoplasty, where both island and perichondrium-preserved palisade graft techniques were used.

RESULTS

The success rates among the study and the control groups with regard to graft take were 97% and 93%, respectively. No significant difference was observed between the groups with regard to the postoperative mean pure tone values, improvement in air-bone gaps and reduction in air-bone gaps to under 20dB. However, better results were observed in the study group.

CONCLUSION

The perichondrium-preserved palisade island graft technique is an easy method with high graft success rates and hearing outcomes.

Cartilage rim augmented fascia tympanoplasty: a more effective composite graft model than temporalis fascia tympanoplasty

OBJECTIVE

To validate a newly introduced cartilage rim augmented temporalis fascia tympanoplasty technique by statistically comparing it with the morphological and audiological outcomes of traditional temporalis fascia tympanoplasty.

METHODS

A retrospective comparative study was conducted on 115 patients who underwent tympanoplasty during 2013 and 2015. Fifty-eight patients underwent temporalis fascia tympanoplasty and 57 underwent cartilage rim augmented fascia tympanoplasty.

RESULTS

In the cartilage fascia group, graft healing was achieved in 94.7 per cent of cases; in the temporalis fascia group, the graft take-up rate was 70 per cent. In those with a normal ossicular chain, the post-operative air-bone gap was within 20 dB in 92.6 per cent of cartilage fascia group cases and in 69.7 per cent of the temporalis fascia group cases, which was a statistically significant difference. Among the defective ossicular chain cases, the post-operative air-bone gap was within 20 dB in 76.9 per cent in the cartilage fascia group, as against 57.1 per cent in the temporalis fascia group.

CONCLUSION

Cartilage rim augmented temporalis fascia tympanoplasty has a definite advantage over the temporalis fascia technique in terms of superior graft take up and statistically significant hearing gain in those with normal ossicular mobility.

Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

OBJECTIVE

To determine which independent variables influence the efficacy of type I tympanoplasty in adult and pediatric populations.

DATA SOURCES

A search of the PubMed database and Cochrane Database of Systematic Reviews using the key words "tympanoplasty OR myringoplasty" from January 1966 to July 2014 was performed.

STUDY SELECTION

Studies reporting outcomes of myringoplasty or Type I tympanoplasty in primary non-cholesteatomatous chronic tympanic membrane (TM) perforation were included.

DATA EXTRACTION

Of 4,698 abstracts reviewed, 214 studies involving 26,097 patients met our inclusion criteria and contributed to meta-analysis.

DATA SYNTHESIS

The primary outcome of success was defined as closure rate at 12 months. The independent variables analyzed were age, follow-up period, approach, graft material, perforation cause, size, location, ear dryness, and surgical technique. Only those studies providing data on a given parameter of interest could be included when comparing each variable.

CONCLUSION

The weighted average success rate of tympanic closure was 86.6%. Based on this meta-analysis, pediatric surgery has a 5.8% higher failure rate than adults and there is no correlation between follow-up period and success. Other variables associated with improved closure rates include perforation with a size less than 50% of total area (improved by 6.1%) and the use of cartilage as a graft (improved by 2.8% compared with fascia), while ears that were operated on while still discharging, those in different locations of the pars tensa, or using different surgical approaches or techniques did not have significantly different outcomes.

The palisade cartilage tympanoplasty technique: a systematic review and meta-analysis

Background

Tympanoplasty is a common procedure performed by Otolaryngologists. Many types of autologous grafts have been used with variations of techniques with varying results. This is the first systematic review of the literature and meta-analysis with the aim to evaluate the effectiveness of one of the techniques which is gaining popularity, the palisade cartilage tympanoplasty. PubMed, EMBASE, and Cochrane databases were searched for "palisade", “cartilage”, “tympanoplasty”, "perforation" and their synonyms.

Main body of abstract

In total, 199 articles reporting results of palisade cartilage tympanoplasty were identified. Five articles satisfied the following inclusion criteria: adult patients, minimum 6 months follow-up, hearing and surgical outcomes reported. Studies with patients undergoing combined mastoidectomy, ossicular chain reconstruction, and/or other middle ear surgery were excluded. Perforation closure, rate of complications, and post-operative pure-tone average change were extracted for pooled analysis. Study failure and complication proportions that were used to generate odds ratios were pooled. Fixed effects and random effects weightings were generated. The resulting pooled odds ratios are reported. Palisade cartilage tympanoplasty has an overall take rate of 96% at beyond 6 months and has similar odds of complications compared to temporalis fascia (OR 0.89, 95% CI 0.62, 1.30). The air-bone gap closure is statistically similar to reported results from temporalis fascia tympanoplasty.

Conclusions

Cartilage palisade tympanoplasty offers excellent graft take rates and good postoperative hearing outcomes for perforations of various sizes and for both primary and revision cases. This technique has predictable, long-term results with low complication rates, similar to temporalis fascia tympanoplasty.

Endoscopic Tympanoplasty Using Nasal Septal Cartilage Allograft

The purpose of the study was to analyze the morphological and functional outcomes in a series of 60 patients for whom Type I tympanoplasty was done using alcohol preserved nasal septal cartilage allograft through endoscopic permeatal route. The study was a prospective, interventional (surgical) study of 60 patients between October 2012 and September 2014. Patients were operated using 0°, 4 mm, 18 cm long Hopkin's rod endoscope through permeatal route. 70% ethyl alcohol preserved allogeneic nasal septal cartilage with thickness of around 0.5 mm was used for grafting. At the end of 6 months, final assessment of morphological outcome i.e. intact tympanic membrane and functional outcome i.e. reduction in Air Bone gap, was done. At the end of 6 months, 57 patients (95%) had intact tympanic membrane. Mean ABG in postoperative patients was 11.83 dB. The operative time taken in 42 patients (70%) was 30-45 min. 42 patients (70%) returned to normal activity in 3-5 days. Endoscopic cartilage tympanoplasty using allogenic nasal septal cartilage can be safely and effectively used for Type I tympanoplasty with good anatomical and audiological results with benefits of reduced operating time, morbidity, pain and 'No scar'.

Is Allergic Rhinitis a Factor That Affects Success of Tympanoplasty?

OBJECTIVE

The aim of the present study was to investigate the effect of allergic rhinitis on the success of the operation in chronic otitis surgery by using score for allergic rhinitis (SFAR).

MATERIALS AND METHODS

In the present study; 121 patients, who underwent type 1 tympanoplasty were examined retrospectively. SFAR of all patients were recorded. The graft success rates of 26 patients with allergic rhinitis (AR) and 95 patients with no allergic rhinitis group (NAR) were compared.

RESULTS

While the graft success rate in NAR group was 89.5%, this rate was 80.8% in the AR group. However, the difference between groups was not statistically significant (p = 0.311).

CONCLUSION

These findings suggest that allergic rhinitis decreases the graft success rate of the pathologies occurring in eustachian tube, middle ear and mastoid although statistically significant difference wasn't found. Prospective studies with larger patient groups are required in order to evaluate this pathology.

The effect of inlay butterfly cartilage tympanoplasty technique on compliance

CONCLUSION

IBCT technique should be preferred owing to its high graft survival rate and ABG gain. While no significant difference was found in middle ear pressures between ears that underwent IBCT and normal ears, compliance values were found to be decreased in patients undergoing IBCT. However, the lack of correlation between ABG gain and compliance values indicated that compliance increase had no effect on post-operative ABG results.

OBJECTIVE

The aim of the present study was to compare tympanometric and audiological parameters in patients undergoing inlay butterfly cartilage tympanoplasty (IBCT) with their normal ears and to determine their difference with normal ear tympanometric parameters.

METHODS

Overall, 25 patients that underwent an operation between August 2010-May 2014 were included in the present study. In 13 of these patients, the ear that did not undergo operation was normal. 0.5, 1, 2, 4 kHz pure sound average values, tympanometric measurements and compliance values of normal and operated ears were compared.

RESULTS

The graft survival rate in patients was found to be 92%. Mean pre-operative air-bone gap (ABG) was 16.4 ± 5.4 in patients, while mean post-operative ABG was 10.9 ± 5.8, with a statistically significant difference (p = 0.001) While there was no significant difference between operated and normal ears of patients in terms of middle ear pressure (0.441), compliance values were significantly higher in normal ears than those in operated ears (0.032). When post-operative ABG gain was compared with compliance values, no significant correlation was found between ABG gain and compliance measurements (r = -0.025 and p = 0.936).

Design, fabrication, and in vitro testing of novel three-dimensionally printed tympanic membrane grafts

The tympanic membrane (TM) is an exquisite structure that captures and transmits sound from the environment to the ossicular chain of the middle ear. The creation of TM grafts by multi-material three-dimensional (3D) printing may overcome limitations of current graft materials, e.g. temporalis muscle fascia, used for surgical reconstruction of the TM. TM graft scaffolds with either 8 or 16 circumferential and radial filament arrangements were fabricated by 3D printing of polydimethylsiloxane (PDMS), flex-polyactic acid (PLA) and polycaprolactone (PCL) materials followed by uniform infilling with a fibrin-collagen composite hydrogel. Digital opto-electronic holography (DOEH) and laser Doppler vibrometry (LDV) were used to measure acoustic properties including surface motions and velocity of TM grafts in response to sound. Mechanical properties were determined using dynamic mechanical analysis (DMA). Results were compared to fresh cadaveric human TMs and cadaveric temporalis fascia. Similar to the human TM, TM grafts exhibit simple surface motion patterns at lower frequencies (400 Hz), with a limited number of displacement maxima. At higher frequencies (>1000 Hz), their displacement patterns are highly organized with multiple areas of maximal displacement separated by regions of minimal displacement. By contrast, temporalis fascia exhibited asymmetric and less regular holographic patterns. Velocity across frequency sweeps (0.2-10 kHz) measured by LDV demonstrated consistent results for 3D printed grafts, while velocity for human fascia varied greatly between specimens. TM composite grafts of different scaffold print materials and varied filament count (8 or 16) displayed minimal, but measurable differences in DOEH and LDV at tested frequencies. TM graft mechanical load increased with higher filament count and is resilient over time, which differs from temporalis fascia, which loses over 70% of its load bearing properties during mechanical testing. This study demonstrates the design, fabrication and preliminary in vitro acoustic and mechanical evaluation of 3D printed TM grafts. Data illustrate the feasibility of creating TM grafts with acoustic properties that reflect sound induced motion patterns of the human TM; furthermore, 3D printed grafts have mechanical properties that demonstrate increased resistance to deformation compared to temporalis fascia.

A comparison of two myringoplasty techniques in Nepalese children: a prospective randomized trial

BACKGROUND

In children, the success of myringoplastywith temporalis fascia is lower compared to adults and cartilage as an alternative graft material has shown higher success rate.

OBJECTIVE

To compare results of myringoplasty using tragal cartilage palisades with the use of temporalis fascia in children with large tympanic membrane perforations.

MATERIALS AND METHODS

This is a prospective and randomized study conducted in children of age 6-14 years with large tympanic membrane perforation of more than two quadrants. Status of graft at or around 6 weeks after surgery was used as morphological outcome measure. Pre- and postoperative audiograms were compared to evaluate audiological outcome in two groups.

RESULTS

Forty seven out of 55 patients completed follow-up. The graft uptake rate in the cartilage palisades and temporalis fascia myringoplasty group was 91.3% (21/23) and 83.33% (20/24), respectively; the difference was not statistically significant (P=0.666). The mean preoperative air-bone gaps (ABG) in cartilage palisades and temporalis fascia group were 36.2±8.9dB and 33.8±7.5dB, the difference was not statistically significant (P=0.412). Similarly, the postoperative ABG in cartilage palisades and temporalis fascia group were 25.1±12.2dB and 17.2±9.2dB, respectively, the difference was statistically significant (P=0.040). The gap closure was 11.0dB in palisades group and 16.8dB in fascia group, but it was not significant (P=0.133).

CONCLUSION

In our study of pediatric myringoplasty, the morphological and functional outcomes in both cartilage palisades and temporalis fascia groups were comparable.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Air space reduction tympanomastoidectomy repairs difficult perforations more reliably than tympanoplasty

OBJECTIVES/HYPOTHESIS

Air space reduction tympanomastoidectomy improves outcomes over tympanoplasty in repairing tympanic membrane perforations in the presence of unfavorable risk factors.

STUDY DESIGN

Retrospective review of 67 subjects' 87 operations.

METHODS

Interventions were tympanoplasty versus air space reduction tympanomastoidectomy. Risk factors were contracted mastoid air cells, previous failed operations, descent from the indigenous peoples of the Americas, and middle/ear mastoid volumes l<3 CC. Favorable outcomes were closure of the perforation, no decline in hearing, and creation of a self-cleaning mastoid bowl.

RESULTS

Five out of 46 air space reduction tympanomastoidectomies failed to close their perforations (11%). Pure-tone threshold (PTA) worsened in 13/46 ears (28%). Four of 46 required mastoid bowl cleaning (9%). In contrast, 21 of 41 tympanoplasties failed to close (51%). PTA worsened in 9/34 ears (26%). All four tympanoplasty failures treated with an air space reduction tympanomastoidectomy closed. Three of the seven tympanoplasty failures treated with a second tympanoplasty did not close. Statistical analysis found two risk factors more prevalent among the air space reduction tympanomastoidectomies: contracted mastoids (P = .019) and middle ear volumes <3 CC (P = .0001). Increased closure of perforations occurring after the air space reduction tympanomastoidectomy was also statistically significant (P = .0002). Descendants of indigenous peoples of the Americas trended toward better PTAs after their air space reduction tympanomastoidectomies than their tympanoplasties and showed statistically significant increases in closure of perforation (P = .0046).

CONCLUSIONS

Air space reduction tympanomastoidectomy is an effective and safe method for closing tympanic membrane perforations.

Is cartilage better than temporalis muscle fascia in type I tympanoplasty? Implications for current surgical practice

The aim of this study was to compare the hearing results and graft integration rates in patients undergoing myringoplasty for the reconstruction of the tympanic membrane, with the use of either cartilage or temporalis muscle fascia (TMF). A systematic literature review in Medline and other database sources up to February 2012 was carried out, and the pooled data were meta-analyzed. Twelve studies were systematically analyzed. One represented level I, one level II and ten level III evidence. The total number of treated patients was 1,286. Cartilage reconstruction was used in 536, TMF in 750 cases. Two level III studies showed a significant difference between the pre- and postoperative air-bone gap closure, in favor of cartilage grafting. The mean graft integration rate was 92.4 % in the cartilage group and 84.3 % in the TMF group (p < 0.05). The rates of re-perforations were 7.6 and 15.5 %, respectively (p < 0.05). Among the other complications of type I tympanoplasty, retraction pockets, otitis media with effusion, anterior blunting, and graft lateralization were usually surgically managed, whereas most of the rest were minor and could be dealt with conservatively. The graft integration rate in myringoplasty is higher after using cartilage, in comparison with fascia reconstructions (grade C strength of recommendation), and the rate of re-perforation is significantly lower. Although cartilage is primarily used as grafting material in cases of Eustachian tube dysfunction, adhesive otitis media, and subtotal perforation in everyday surgical practice, a wider utilization for the reconstruction of the tympanic membrane in myringoplasties can be recommended.

Cartilage graft or fascia in tympanoplasty in patients with low middle ear risk index (anatomical and audological results)

The aim of this study was to compare anatomic and audiological results of cartilage graft with temporal fascia graft in type 1 tympanoplasty patients with low middle ear risk index (MERI). In this retrospective study, 63 patients that underwent type 1 tympanoplasty with chondroperichondrial island graft between July 2009 and November 2010 were compared with 45 patients in whom temporal muscle fascia was used. Patients in both groups had low MERI values varying between 1 and 3. Five and nine patients underwent masteidectomy in cartilage and fascia group, respectively. Mean duration of follow-up was 11.9 ± 3.7 (5-17) months. Mean value was calculated at pre-operative and post-operative hearing threshold 0.5, 1, 2, 4 kHz, and air bone gap (ABG) gain was compared in both cartilage and fascia groups. when pre-operative and post-operative ABG gain were compared, significant decrease was seen in ABG levels (p < 0.001). However, no significant difference was seen in ABG gain values (p = 0.608), which was 10.1 ± 7.00 dB in cartilage group and 10.8 ± 5.38 dB in fascia group. In both groups, age, sex, and the addition of mastoidectomy procedure had no significant effect on ABG gain and success. Cartilage is a graft material that may be preferred without concern about the effects on hearing results, especially, in patients with low MERI values. The addition of mastoidectomy had no impact on the outcome of operation and audiological results. However, further studies with larger case series may be carried out to further clarify the issue.

Usefulness of cortical mastoidectomy in myringoplasty

OBJECTIVES

The usefulness of cortical mastoidectomy in myringoplasty remains an issue of controversy. We aimed to assess the effectiveness of mastoidectomy on outcomes of tympanoplasty performed in patients with persistent or intermittent discharging chronic suppurative otitis media without cholesteatoma.

STUDY DESIGN

Prospective, randomized, single-blinded study. Level of evidence-1B.

SETTING

Tertiary referral center.

PATIENTS

Three hundred twenty consecutive adult patients presenting persistent or intermittent otorrhea during the preceding 6 months scheduled for myringoplasty were included.

INTERVENTIONS

Patients were randomly assigned to undergo either myringoplasty with cortical mastoidectomy (Group A) or myringoplasty only (Group B).

MAIN OUTCOME MEASURES

Graft success rate and mean postoperative air-bone gap. Auditory outcomes were evaluated at one year postoperatively.

RESULTS

At the end of the follow-up period, there were 24 failures within Group A (success rate, 82.8%) and 34 within Group B (success rate, 76%), statistically not significant. In the univariate analysis, 3 factors were found to be significant in predicting success rate: healthy opposite ear, a long dry period preceding the operation and nonsmoker status. The only factor attaining significance in the multivariate analysis was a dry period longer than 3 months.

CONCLUSION

Cortical mastoidectomy offers no additional benefit in myringoplasty performed on patients with persistent or intermittent discharging CSOM and no evidence of cholesteatoma or mucosal blockage within the antrum.

Randomized study comparing fascia and cartilage grafts in myringoplasty

OBJECTIVES

The study compares the medium-term outcomes of myringoplasty procedures using fascia and cartilage grafts.

METHODS

Patients with chronic otitis media with perforations larger than 50% of the size of the tympanic membrane were included in a randomized, controlled, prospective clinical trial. The perforations were repaired with either temporalis fascia (20 ears) or cartilage (18 ears) grafts selected randomly. A search of the literature was performed to look for other randomized studies comparing fascia and cartilage.

RESULTS

The graft take rates of fascia and cartilage grafts at 24 months were 84.2% and 80%, respectively. The postoperative air-bone gaps and hearing gains at 24 months were 16.97 dB and 13.63 dB, respectively, in the fascia group and 20.63 dB and 12.60 dB, respectively, in the cartilage group. There was no significant difference in the graft take rates or postoperative hearing between the two groups. The literature search identified one other randomized study comparing fascia and cartilage grafts in the repair of large perforations. The pooled data from the two studies did not show a difference in the graft take rates or hearing gains between cartilage and fascia.

CONCLUSIONS

There was no statistical difference in the outcomes of fascia and cartilage grafts in the repair of large perforations.